LIBRARY OF CONGRESS. \ 

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Chap........'. Copyright No,......_ 

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UNITED STATES OF AMERICA. 






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ASEPSIS 

OR 

Surgical Cleanliness 

A Manual for Physicians, Students and Nurses 



BY 



L. D. ROGERS, A. M., M. D, 

PROFESSOR OF SURGERY IN THE NATIONAL 
MEDICAE UNIVERSITY, CHICAGO. 



CHICAGO 
PEOPLES HEALTH JOURNAL CO., 

1900. 



1 



TWO COPIES RECEIVE^ 

Library of c©Bgre«^ 

MAR 28 1900 


KsgUfer of Copyrfghf^ 




1K& 



56663 



Copyright 1900 
By L. D. ROGERS. 



SECOND COPY, 

\ «3 o o * 



PREFACE. 



One Sunday morning, some five years ago, a 
bright, active, robust woman about thirty years 
of age called on the writer and introduced herself 
by saying in the most engaging manner: Pardon 
me, Doctor, for disturbing you upon the Sabbath, 
but I have come to offer you my services. I am 
a medical stenographer. I see by your "ad" in 
this morning's Tribune that you are in need of 
such a person. 

A few moments conversation made it evident 
that she was a lady of rare intelligence and an 
expert nr her chosen field, being able to spell 
readily the most difficult medical terms and to 
write them with the machine almost as rapidly as 
they could be spoken. Her references showed 
that she had done special work for many promi- 
nent physicians and surgeons. 



IV PRE FA CE. 

She was subsequently engaged for the special 
purpose of taking dictations for this book on 
Surgical Cleanliness. To our encouragement and 
delight she entered upon her work with intelli- 
gent enthusiasm and seemingly took as much 
pride in its proper and early completion as the 
author himself. 

However, before the manuscript was half com- 
plete she surprised us one day by announcing, that 
she had an abdominal tumor and had already made 
arrangements to enter a hospital at once to un- 
dergo an operation for its removal. Our sugges- 
tion to postpone matters for further deliberation 
was rejected and we accepted her invitation to be 
present at the operation, as a spectator. An 
ovarian cyst, the size of an orange, was removed. 
On the third day after the operation she had a 
chill. Her temperature rose, and from that time 
she suffered horribly until the thirteenth day, 
when she died. We were also present at the 
post mortem examination, which revealed a quart 
of pus in the abdominal cavity, and fully a pint 
in each pleural cavity. 

Such a pronounced case of blood poisoning w r e 
never expect to witness again. Why did she have 



PREFACE. v 

blood poisoning? Undoubtedly some one was not 
surgically clean during that operation. It may 
have been a nurse or an assistant or the operator 
himself. Possibly, the instruments or dressings 
were infected by the touch or the breath of an 
unclean spectator. Perhaps the nurse who pre- 
pared the instruments and dressings, or the one 
which prepared the field of operation, was not 
conscientious in performing her work thoroughly. 
Since the life of Lilian Bonner was thus sacrificed 
by the lack of surgical cleanliness in an established 
hospital under the hands of a reputable surgeon, 
we have not deemed it necessary to offer any 
apology for the publication of this book. 

This volume is the outgrowth of a lecture first 
delivered several years ago before the students of 
the National Medical University. It has since 
been revised several times, and repeated to stu- 
dents and nurses with a view of preparing them 
to enter the operating room and be safe assistants. 
Few things are more exasperating to a clean sur- 
geon than to have present during an operation 
officious persons who have no idea of surgical 
cleanliness. 

If spectators possess even a theoretical know- 
ledge of the subject it is a great comfort to the 



VI PREFA CE. 

surgeon and an inmense advantage to the patient. 
They will know enough to keep out of the way of 
the operator, the assistants and the nurses. They 
will stand off at such a distance that they cannot 
breathe, spit or shake germ laden particles into the 
wound. They will ' 'touch not, handle not" any- 
thing with unclean hands. They will also know, 
that in order to get the hands surgically clean it 
requires a good deal more than simply rinsing 
them off in a basin of water containing a few 
drops of some antiseptic. They will have learned, 
that the song of the surgically clean surgeon is 
' 'scrub! scrub! scrub! for ten minutes with the 
scrub brush, scrub! soap and water!" 

I,. D. R. 
441 Dearborn Ave., Chicago, March i, 1900. 



CHAPTER I. 

In the dirt under our finger nails, in the creases 
and folds of the skin, upon the hair, in the secre- 
tions from the nose, the mouth, the eyes, the ears, 
and from all the other orifices of the body there 
may be found by the aid of the microscope, germs 
which are capable of spoiling the best efforts of the 
most skillful surgeon. 

These germs are the cause of pus, the yellow, 
creamy, or dirty mattery discharge seen in boils, 
abscesses and all unhealthy wounds. No genuine 
pus can occur without them. They are always 
present in pustules, in boils, in abscesses, in fel- 
ons, in carbuncles, in purulent inflammation, and 
wherever there is suppuration or maturation. 
None of these affections can occur without them. 
They are the cause of every one of them. They 
are always the cause of septicemia, pyeamia and 
blood poisoning in general. Without these germs 
it would be impossible to have a case of blood poi- 
soning or child-bed fever. 

7 



8 SURGICAL CLEANLINESS. 

They are the surgeon's most dangerous enemy. 
They may transform the simplest operation into 
one of great gravity. They have often brought 
about a fatal result where it was least expected. 
We have recently Seen a young man whose left 
knee was as stiff as though there had never been 
any joint. A few years ago he accidentally ran a 
sewing needle into it. Either by the needle or by 
the instrument of the doctor who searched for it 
pus germs were conveyed into the joint. An ab- 
scess resulted which entirely destroyed the joint 
and nearly the life of the boy. 

This case reminds me that some thirty years ago 
when a small boy we were told that if the knee 
was injured so that the ' 'joint water" escaped, it 
would always after that be stiff. Now, we know 
that the cavity of the knee joint, as well as that 
of any other cavity of the body, may be opened 
with impunity, provided that pus germs do not 
gain admittance. 

Formerly, it was supposed that the formation of 
pus in a wound was a natural and necessary step 
in the process of healing. Now the suppuration 
of a wound is regarded as an unnatural, unneces- 
sary and dangerous complication. Instead of facil- 
itating healing it greatly retards. 

How the view of surgeons regarding pus has 
changed during the past quarter of a century is 
well illustrated by the following two incidents, the 
truthfulness of which we do not question. 



SURGICAL CLEANLINESS. 9 

It is related that in the year 1870 one morning 
as the surgeon-in- chief of a large hospital was mak- 
ing his usual rounds of the surgical wards, he 
said to the house surgeon : 

"How is that amputation case to-day?" 

"Doing splendidly," was the reply, "the wound 
is suppurating beautifully. ' ' 

"That's good," said the chief, and passed on 
smiling, evidently satisfied with the condition of 
the case. 

The second incident is said to have occurred in 
the year 1895, in the same ward of the same hos- 
pital, but the surgeons and the patient were differ- 
ent. The surgeon- in- chief one morning asked the 
same question that his predecessor had asked just 
twenty- five years before. The answer was : 

"Doing badly, sir, the wound is suppurating." 

The exclamation of the chief upon hearing this 
was more emphatic than elegant. It was evident 
that he was disappointed and chagrined. 

The reason for it is easily understood when it is 
known that the modern surgeon very rightly con- 
siders it a positive disgrace to have pus occur in 
a w r ound of his own making. It is almost con- 
clusive evidence that he or his assistants or his 
nurses have been unclean from a surgical stand- 
point. 

In the light of modern surgical science, avoida- 
ble uncleanliness must be classed as criminal 
carelessness. 



io SURGICAL CLEANLINESS. 

An old soldier who lost a leg in the Civil war 
told us that a few days after his thigh was ampu- 
tated the assistant surgeon ventured the opinion 
that the wound would heal by first intention, that 
is, without suppuration. On hearing this the 
surgeon of the regiment ridiculed the young sur- 
geon unmercifully for entertaining for a moment 
the absurd idea that an amputation could heal 
without suppuration. But bacteriology, that sci- 
ence which has practically grown up since 1882, 
when Dr. Robert Koch discovered the bacillus of 
tuberculosis, has taught us that any wound which 
is kept free from pus germs, that is aseptic (sur- 
gically clean), will heal without suppuration and 
even without inflammation. 

The discovery of this single truth has caused 
the most astonishing reduction in the mortality of 
surgical cases. No other discovery in the whole 
realm of surgery, either ancient or modern, equals 
in importance the simple fact which may be ex- 
pressed in a sentence of five words, namely : 
Aseptic wounds heal without suppura- 
tion. 

A quarter of a century ago, before this golden 
truth was discovered, the most experienced and 
skillful surgeons regarded the result of their oper- 
ations as a matter of chance. If their patients 
escaped the scourges of surgery, namely : suppur- 
ation, purulent edema, hospital gangrene, erysip- 
elas and tetanus, it w r as considered rare good luck, 



SURGICAL CLEANLINESS. n 

and in no way due to their knowledge or skill. In 
these days he knows that he will have no pus if 
he has been clean surgically. 

After a bloody operation the surgeon had no more 
control over the outcome of it than the farmer has 
over the mighty elements which develop or blast 
the crops he has planted. 

In pre-aseptic times the mortality from amputa- 
tion reached sixty per cent. In Nussbaum's 
clinic, at Munich, it is said that eighty per cent, 
of all wounds were attacked with hospital gan- 
grene. Erysipelas was the rule rather than the 
exception. It was the custom not to suture scalp 
wounds because they always suppurated. Sutur- 
ing, by retaining the secretions, seemed to favor 
the development of erysipelas. During one year 
in this clinic out of seventeen cases of amputation 
eleven died of pyaemia. It was a rare occurrence 
to see a case of open or complicated fracture which 
was not attacked in a few days with septicaemia or 
one of its companion diseases and end fatally. 
The rule was, therefore, to amputate the limb 
whenever there was an open fracture, that is, 
one where the air communicated with the bone. 

Since writing the foregoing we have visited the 
hospitals of Munich. We did not see a single case 
of blood poisoning of any kind. We noticed that 
the strictest surgical cleanliness was observed in 
all operations. Before the days of antiseptics the 
French hospitals showed a death rate of fifty-two 



12 SURGICAL CLEANLINESS. 

and one-half per cent, after all major operations. 

From 1850 to 185 1 there were treated in the 
Pennsylvania hospital at Philadelphia one hundred 
and sixteen cases of compound fracture. Exclud- 
ing the cases in which amputation was performed, 
there were fifty-one deaths — a mortality rate of 
forty-four per cent. 

During the same period in the New York hos- 
pitals, one hundred and twenty-six cases of com- 
pound or open fracture were treated. Excluding 
amputation cases, sixty-eight died — a mortality 
rate exceeding forty-eight per cent. 

During the period from 1866 to 1876 there w T ere 
treated in the surgical clinics of Vienna and Zur- 
ich one hundred and eighty cases of open fracture. 
Excluding amputation cases, the death rate w r as 
forty-one per cent. At St. Petersburg one hun- 
dred and six cases of open fracture resulted in a 
mortality of sixty-eight per cent. 

During the period from 1841 to 1861, in Guy's 
hospital, London, there were fifty deaths out of 
two hundred and eight cases treated- — a mortality 
rate of twenty- four per cent. 

The average mortality for these seven hundred 
and thirty-six cases of open fracture, representing 
all the great hospitals and surgeons in the world, 
was forty -five per cent. 

Upon the introduction of antiseptic methods 
the mortality rate in open fractures dropped to 
four per cent. 



SURGICAL CLEANLINESS. 13 

In Volkmann's clinic, at Halle, the mortality 
rate in open fractures was above forty per cent. 
His predecessors for a number of generations had 
had about the same result in such cases. 

In the years 1871 and 1872 the death rate was 
so enormous from pyemia and erysipelas that this 
distinguished surgeon was on the point of closing 
his wards. Out of twelve cases of open fracture 
under his care all died. As a last resort, he began 
the use of the antiseptic methods then being intro- 
duced by Sir Joseph L,ister. During the succeed- 
ing ten years, up to 1 88 1, he had one hundred 
and thirty-five cases of open fractures and did not 
lose one from blood poisoning. His mortality 
rate in all cases dropped to six per cent. 

It was our privilege to see every case in the 
wards of this most interesting of all German hos- 
pitals. We know that the death rate now is very 
small. 

Lister observed, as had many surgeons before 
him, that simple fractures — those in which the 
skin was not broken — were attended with but little 
risk to life, while Open fractures had a general 
mortality rate, as we have already seen, of forty- 
five per cent. 

He reasoned that the atmosphere must contain 
some deleterious element which decomposed the 
blood and rendered it a poisonous irritant, causing 
severe constitutional disturbances and frequently 
death. 



14 SURGICAL CLEANLINESS. 

In an article in the London Lancet during Sep- 
tember, 1867, he first published his theory of 
antiseptics. Lister discovered no new principle. 
Heuter had said twenty-five years before: "No 
germ, no pus." As early as the year 1837, 
Schawnn had demonstrated the connection be- 
tween putrefaction and micro-organisms. 

But it was the precision and accuracy of Pas- 
teur, a quarter of a century later, which convinced 
the scientific world of this truth and gave Lister 
the foundation upon which to build his system of 
antiseptics. 

Lister attempted to keep the germs out of the 
wounds by protective bandages and also to destroy 
them by a germicide. 

On account of its deodorizeng qualities he se- 
lected carbolic acid. He washed and sprayed 
wounds with a solution of this agent. Then 
wrapped them in gauze impregnated with it and 
over all he placed an air-tight dressing. 

During the period from 1864 to 1866, inclusive, 
Lister operated at Glasgow. His mortality rate 
for all kinds of operations was nearly 46 per 
cent. From 1867 to 1869 he employed his anti- 
septic methods to a limited extent and his mor- 
tality rate sank to 15 per cent. From 1 871 to 1876 
inclusive, after he had improved details, he treated 
553 grave surgical cases with a death rate of 
thirty-six hundredths of one per cent. 

Thus it is seen that his death rate before he 



SURGICAL CLEANLINESS. 15 

employed antiseptic methods was 127 times 
greater. 

Notwithstanding this immense reduction in the 
mortality rate obtained through L,isterism subse- 
quent knowledge has shown that while the prin- 
ciple upon which he acted was entirely correct his 
technique or method was imperfect. 

He inaugurated a new era in the surgical 
world, which has led to more advancement in 
surgery during the last twenty years than during 
the previous two thousand years. 

Notwithstanding the unquestioned truth of his 
theory and superior results achieved by it, time 
was required for its introduction and adoption into 
the great surgical clinics and hospitals of the 
world. 

As late as 1876 the famous old surgeon Van 
Langenbeck said to his students: "A new method 
has been advanced by an English surgeon who 
predicates the principle of wound treatment upon 
the destruction of organic germs w T hich he assumes 
to be the cause of wound disturbances. The ex- 
cellent results claimed by him are not in accord 
with what we obtain. Hence, I can hardly grasp 
their perfection. Yet, notwithstanding my exper- 
ience, I feel it incumbent upon me to test them in 
practice. " 

The extent of the adoption of Iyisterism in the 
United States may be estimated by recalling some 
facts connected with the treatment of the case of 



16 SURGICAL CLEANLINESS. 

President Garfield. During the month of June, 
1 88 1 he was shot in the back. We were recently 
told by one of the surgeons who attended him that 
they each inserted their fingers into the wound 
without even taking the precaution to wash their 
hands. In the light of surgical science of to-day, 
it is easily understood why the lamented president 
had septicaemia, dying three months later of 
pyaemia a victim of ignorance. He is supposed 
to have had the best surgical skill the nation could 
afford at that time. At the present the poorest 
pauper who attends the free dispensary receives 
better treatment than our president received only 
eighteen years ago. 



CHAPTER II. 

While Pasteur had proved that putrefaction was 
due to germs and Lester had done much toward 
devising methods to successfully overcome their 
deleterious effects it remained for Koch to inaug- 
urate a line of scientific investigation, beginning 
with the discovery of the bacillus of tuberculosis 
in 1882 and reaching its climax in 1885 by the 
discovery and complete identification of the more 
important of the pUS germs. 

Up to the present about twenty different germs 
have been identified which are capable of produc- 
ing pus. To all of these the term pyogenic is 
applied, meaning pus producing. 

The yellow pus germ is the one of greatest im- 
portance to the surgeon. Its scientific name is 
staphylococcus pyogenes aureus. The 
word staphylo is derived from the Greek and 
signifies a bunch of grapes. COCCUS is also from 
the same source and originally meant a pill or ker- 
nel. It is now applied to all germs having a glo- 

17 



1 8 SURGICAL CLEANLINESS. 

bular shape. The first part of the word pyo- 
genes means pus, the second part generating or 
producing. Aureus, of course, indicates golden 
or j^ellow, and is used because this germ produces 
a yellow pus. This long name is applied therefore 
to globular-shaped germs which are found in clus- 
ters resembling bunches of grapes, and which pro- 
duce pus of a golden yellow. If a small particle 
of yellow pus be implanted in sterilized gelatine 
and kept at blood temperature for two or three 
days the gelatine will become liquified around and 
about the point of implantation of the pus, and a 
golden deposit appear. This yellow deposit and 
the liquefaction of the gelatine are two character- 
istics which taken together distinguish this germ 
from all others. 

Another way of ascertaining the presence of this 
germ is to implant upon the cut surface of a boiled 
potato a minute quantity of material suspected of 
containing the germ. Place it in a sterilized tea 
cup or glass jar and cover tightly with a piece of 
sterilized window glass so that no other germ can 
come in contact with the contents. If the yellow 
pus germ is present after two or three days, dur- 
ing which time the potato has been kept in a room 
at blood temperature, the characteristic yellow 
deposit will be seen at the point of implantation, 
and a marked softening of the substance of the 
potato will be observed. 

If a small quantity of this yellow deposit from 



SURGICAL CLEANLINESS. 19 

either the potato or gelatine be transplanted into 
a fresh wound upon a guinea pig or any other 
susceptible animal or human being, suppuration 
will occur, amounting in some cases to general 
blood poisoning and even death. 

Gar re inoculated a small wound on the end of 
his ringer with a small quantity of pure culture of 
this germ. An ulcer formed around the margin 
of the finger nail. From the pus thus formed he 
made cultures of the germ and then rubbed a con- 
siderable quantity upon the unbroken skin of his 
left forearm. A large carbuncle formed, sur- 
rounded by daughter carbuncles, at the point of 
application of the culture. They ran the usual 
course, requiring several weeks before healing was 
complete. Seventeen scars were left to bear testi- 
mony to the success of the experiment. 

If such results follow the simple rubbing of the 
germ into the unbroken skin what must be expec- 
ted when it is conveyed directly into a wound by 
dirty fingers or dirty instruments ? 

The Staphylococcus pyogenes aureus, 
• the yellow pus germ, is found in greatest abun- 
dance upon the skin and mucous membranes. 
Particularly where the skin lies in folds and is 
moist, as for instance, the arm pits and the groins. 
It may be found at all the orifices of the body and 
in all of the secretions. It may be found upon 
soiled clothing, unwashed instruments, in dust 
upon the furniture and upon the floor or walls. 



20 SURGICAL CLEANLINESS. 

It is sometimes found in water and occasionally in 
the air. 

A single yellow pus germ is seven-tenths of a 
mikron in diameter. It would take 40,000 of 
them placed in a line to measure one inch. A 
thousand of them could be packed wdthin a red 
corpuscle. 

The yellow pus germ has been found not only 
in furuncles or carbuncles, but in pustular affec- 
tions of the skin and mucous membranes, namely: 
impetigo, sycosis, phlytenular conjuntivitis, pur- 
ulent conjuntivitis, acute abscesses of the lympha- 
tic glands, salivary glands, tonsils and mammary 
glands, and in metastatic abscesses and purulent 
collections of joints, in acute suppurative osteo- 
myelitis and suppurative endo-carditis. 

After the discovery and identification of this 
pus germ the intensely practical question arose as 
to w T hat w r ould destroy it or neutralize its deadly 
ravages. 

Numerous experiments have been made with it 
as w y ell as with all the other important pathogenic 
germs to determine the thermal death point. 
It has been found that an exposure of 10 minutes 
in water at a temperature of 143.6 Fahrenheit w 7 ill 
completely kill the staphyloccocus pyogenes 
aureus. Boiling water (212 degrees Fahrenheit) 
is therefore more than sufficient to destroy it. It 
becomes then an easy matter to disinfect and make 
surgically clean any instrument or article w r hich 



SURGICAL CLEANLINESS. 21 

can be boiled, but the great problem is how to 
render the skin and catgut or other aninaml sub- 
stance free from these germs. 

A one per cent, solution of carbolic acid will de- 
stroy the germ in two hours. 

A solution of bi-chloride of mercury of one to 
one thousand per cent, will kill the germs within 
eight seconds. 

The bin-iodide of mercury has twice the anti- 
septic power of the bi-chloride of mercury. 

Thus far we have described only the staphylo- 
coccus pyogenes aureus, the most common and the 
most important of all the pus producing germs. 
Before discussing antiseptics in detail we shall 
enumerate and describe other germs against which 
the surgeon has to contend. 

There are several varieties of the staphylococcus 
pyogenes. We have fully described one, the 
aureus. The albus is another. It is found 
chiefly upon the skin. In every respect, except 
in color, it closely resembles the aureus — the sur- 
face cultures upon nutrient agar or potato have a 
milk-white color. It lacks the golden hue so 
characteristic of the aureus. Hence its name, 
albus, which implies white. It is less virulent 
than the aureus. 

For the purpose of testing the comparative 
pathogenic properties of the yellow and white pus 
germs, an instrument infected with the yellow 
was stuck through the cornea of the eye. Pan- 



22 SURGICAL CLEANLINESS. 

of the eye developed within thirty hours. When 
the instrument was infected with the white pus 
germs, the panophthalmitis did not develop until 
sixty or seventy-two hours had elapsed. 

When the instrument was inserted in a through- 
ly sterilized condition, that is entirely free from 
all germs, no inflammation of the eye followed. 
The wound readily healed without causing any 
trouble whatever. 

A bacteriological examination of nineteen cases 
of panophthalmitis demonstrated the white staphy- 
lococcus in ten and the yellow in nine. 

There is a variety of the white pus germs, 
named by Welch, staphylococcus epidermis albus. 
It is regarded as a regular inhabitant of the nor- 
mal skin, just as the bacillus coli communis is of 
the intestinal canal. 

It liquifies gelatine and coagulates milk more 
slowly than the ordinary pus germ. A peculiarity 
of this geim is that it is very often found in layers 
of the epidermis deeper than can be reached by 
any known means of cutaneous disinfection. After 
sterilization of the surface of the skin so that 
scrapings develop no germs, the presence of this 
germ may be demonstrated in a piece of the skin, 
or on a suture which has passed through the en- 
tire thickness of the skm. This skin coccus may 
often be found in wounds without causing suppur- 
ation. 

It is likely, however, to cause suppuration if 



SURGICAL CLEANLINESS. 23 

there is any foreign substance in the wound. It 
is , therefore, a common cause of stitch abscesses. 
It is likely to follow down drainage tubes and 
cause suppuration. This explains how stitch ab- 
scesses may sometimes occur after an operation 
which has been performed under perfectly aseptic 
precautions. 

Lockwood, of London, has described a diplo- 
coccus epidermis albus which closely resembles the 
ordinary white pus germ. It produces a peculiar 
odor as it grows, such as is smelled when unclean- 
ly persons remove their chothing. 

Incidentally, w r e would call attention to the fact 
that the bacillus prodigiosus produces a deep red 
deposit and this, perhaps, accounts for the blood- 
red stains seen in the clothing about the armpits 
of some persons. 

The streptococcus pyogenes is next in im- 
portance to the staphylococcus pyogenes aureus. 
It is supposed to be identical with the erysipelas 
germ, known as the streptococcus of erysipelas. 
This germ is found in chains and not in grape-like 
bunches, as is the staphylococcus. The word 
Strep to refers to a chain. Hence the term strep- 
tococcus pyogenes refers to pus-producing, globu- 
lar germs so arranged as to give a chain-like 
appearance. It is frequently spoken of as the 
chain coccus. Usually five to ten of these germs 
are seen in a string. This arrangement facilitates 
the passage of a group of them through lymphatic 



24 SURGICAL CLEANLINESS. 

vessels more readily than the bunched arrange- 
ment of the staphylococcus. Probabty this ac- 
counts for the fact that we more often find the 
latter in circumscribed, localized suppuration and 
the former in diffused suppuration, as lymphangi- 
tis, cellulitis, and erysipelatoid inflammations. 

The spreading nature of erysipelas may be ex- 
plained by the proneness of this germ to insinuate 
itself along the lymphatics. It also explains the 
red streaks which may often be seen extending up 
an arm or leg after an infected wound of the hand 
or foot. In the lymphatics the streptococcus py- 
ogenes causes lymphangitis, and when it reaches 
a lymphatic gland it sets up a suppurative adenitis. 
This again explains the enlarged and sore glands 
that may be felt when an infection at an extrem- 
is traveling toward the trunk. 

The streptococcus pyogenes causes acute sup- 
puration almost as frequently as the staphylococcus 
pyogenes aureus. Out of thirty-nine cases of 
acute pus formation it was found to be the sole 
cause in fifteen of them and in five of the remain- 
ing cases it w r as found associated with the staphy- 
lococcus. 

It is found almost invariably associated w T ith 
puerperal or child-bed fever. This fact explains 
the observation made long before the days of bac- 
teriology, namely : if a physician went from a 
case of erysipelas to a confinement case the wo- 
was almost certain to have child-bed fever. This 



SURGICAL CLEANLINESS. 25 

was such a common result that conscientious phy- 
sicians in former times would not attend an obstet- 
rical case at the same time they were visiting a 
case of erysipelas. 

Since physicians have learned how to disinfect 
themselves of all pyogenic germs they may now 
attend at the same time, without jeopardizing the 
lire of the woman, a case of erysipelas and one of 
obstetrics provided, of course, that they disinfect 
thoroughly. 

In former times it was noticed that if a physi- 
cian had one case of child-bed fever he generally 
had several in succession. It was a co union oc- 
currence for some certain physician to have so 
many cases of puerperal fever that he would be 
compelled to give up obstetric practice for months. 
While visiting near Ogden, Utah, in 1894, w T e 
heard of a country doctor who had lost nine wo- 
men from child-bed fever in rapid succession. 
Popular indignation became so great that he w r as 
compelled to abandon obstetric practice entirely. 
It was very evident that he did not understand 
surgical cleanliness. 

It should be remembered that the streptococcus 
pyogenes is a widely distributed micro-organism. 
It may be found in almost as many different places 
as the stapnylococcus. A favorite abode, how- 
ever, is upon the mucous membrane at all the 
orifices of the body, even in cases of apparently 
healthy persons. Its presence in the vagina wall 



26 SURGICAL CLEANLINESS. 

explain why it is commonly, if not always present 
in child-bed fever. 

Its presence in the mouth will account for some 
of the cases of blood poisoning following a bite by 
a human being. 

How the presence of this germ in the nasal se- 
cretions may be the source of serious infection is 
illustrated by the experience of a Philadelphia 
physician many years ago. No matter what pre- 
cautions he took his obstetrical cases usually de- 
veloped child-bed fever. He had forty-five cases 
in one year. Other physicians in the same neigh- 
borhood, who took far less precaution than he, 
had little trouble of this kind. 

It is related that in order to "rid himself of the 
mysterious influence which seemed to attend upon 
his practice he left the city for ten days, and be- 
fore waiting on the next parturient case he had 
his hair shaved off and put on a wig, took a hot 
bath and changed every particle of his apparel, 
taking nothing with him that to his knowledge he 
had worn or carried on any former occasion. Mark 
the result. The lady, notwithstanding that she 
had an easy parturition, was seized the next day 
with child-bed fever and died on the eleventh day 
after the birth of the child. Two years later he 
made another attempt at purification and the next 
case fell a victim to the same disease. ' ' An ex- 
haustive investigation developed the fact that the 
unfortunate doctor was afflicted with a persistent, 



SURGICAL CLEANLINESS. 27 

purulent nasal catarrh which , doubtless, kept his 
hands infected. The benefits which the practice 
of obstetrics have derived from bacteriology ex- 
ceed the most extravagant estimates. 

Buchanan, in his valuable little book entitled, 
"Antisepsis and Antiseptics," says that about 
thirty years ago the mortality in lying-in hospitals 
was so great that the International Congress of 
Physicians and Surgeons, at its session in Brus- 
sels recommended the abolishing of such institu- 
tions. 

Observations in Europe and America, extend- 
ing over a long period of time, confirm the fact 
that wherever a large number of lying-in women 
were congregated puerperal septicemia prevailed, 
and the death rate was appalling. 

In the years 1760, 1768 and 1770, the disease 
prevailed to such an extent in London that in 
some of the maternity hospitals nearly all of the 
patients died. In the Royal Infirmary at Edin- 
burg, in the year 1773, "almost every woman as 
soon as she was delivered, or perhaps twenty- four 
hours after, was seized with it and all of them 
died. 

"In the Maison d'Accouchments at Paris dur- 
ing several years the death rate was so high that 
of every three women who entered the institution 
one died. 

"In the hospitals at Vienna in 1823 nineteen per 
cent, of the cases died ; in 1842 sixteen per cent. 



28 SURGICAL CLEANLINESS. 

"In the lying-in hospital at Berlin in 1862 
hardly a single patient escaped death from child- 
bed fever. As a result of this terrible mortality 
the institution was closed." 

Now, conditions are reversed. A woman runs 
less risk of incurring child-bed fever in a well- 
regulated lying-in hospital than she does at home. 

Now, in many of the large lying-in hospitals, 
the death rate from puerperal fever is about one- 
tenth of one per cent., or one in a thousand. 

Master Smiley, the chief medical officer of 
the Rotunda Hospital at Dublin, within whose 
walls 220,000 women have been delivered within 
the past 145 years, told us during our recent visit 
to the famous institution that they scarcely knew 
what child-bed fever was. 

Dr. Griffith, attending physician at the Queen 
Charlotte Lying-in Hospital, London, where about 
1,200 women are confined annually, told us that 
for several years they had had no deaths from 
child-bed fever. 

In the New York Maternity Hospital, from 
1875 to 1883 inclusive, 3,504 women were con- 
fined. Of this number 146 died from puerperal 
fever. Beginning with the year 1884, antiseptic 
methods were emplo3 r ed. From that time until 
1891 inclusive, 3, 170 women were delivered with 
only seven deaths from child-bed fever. 

Since the era of antiseptic and aseptic methods, 
Merman, of Manheim, reports 700 deliveries in 



SURGICAL CLEANLINESS. 29 

succession before a death occurred, and Braum, of 
Vienna, reports two deaths in 1,004 cases. 

The latest researches indicate conclusively that 
the streptococcus pyogenes is the usual cause of 
child-bed fever. In 81 cases of puerperal fever 
this was found in the discharges from 35 of them, 
while an examination of the discharges of 57 wo- 
men who were free from puerperal fever during 
confinement did not reveal this germ in a single 
instance. In ten fatal cases of child-bed fever 
the streptococcus in every case was found in the 
discharges during life and in the organs after 
death. 

The streptococcus is more easily destroyed than 
the staphylococcus. The former is destroyed in 
ten minutes at a temperature of 130 , while the 
thermal death point of the latter is 144 . The 
streptococcus is killed within eight seconds in a 
three per cent solution of carbolic acid. 

In the mouth beside the streptococcus already 
described more than one hundred different germs 
have been identified. The decay of the teeth is 
caused no doubt by certain germs. Most of the 
germs found in the mouth are harmless, and may 
even serve a useful function. 

One of the most important germs commonly 
found in the mouth is the pneumocOCCUS — the 
pneumonia germ. It is often found in the saliva 
of an apparently health}' person. The virulency 
of this germ varies in different persons; and it also 



30 SURGICAL CLEANLINESS 

varies in the same person at different times. Sa- 
liva containing the pneumococcus injected into 
susceptible animals — mice, rabbits and guinea pigs 
— will kill them at one time, while at another it 
may not. This fact demonstrates the marked 
variability in the degree of virulence of this germ. 

Next to the staphylococci and streptococci, it is 
the most common cause of inflammation. It is 
believed to be the sole specific cause of acute lobar 
pneumonia, and very often the cause of broncho- 
pneumonia, abscess of the ear and meningitis. 
The list of diseases which it is capable of produc- 
ing is very long. It may cause inflammation any- 
where in mucous or serous membrane. It can 
cause an abscess in any part of the body. It is 
the most frequent cause of pus in the pleural cav- 
ity, that is, pleural empyemia. This germ is de- 
stroyed in ten minutes in water at a temperature 
of 126 Farhenheit. It may live four months in 
dried blood or sputum. While it may cause the 
gravest diseases, it is generally a benign organism 
in comparison with the streptococcus. 

Bacillus coli communis is the name of a 
germ that is a constant inhabitant of the intestine. 
It is also found widely distributed outside of the 
body. It is an important factor in inflammation 
of the urinary tract and the ducts of the liver. It 
is found as a rule in appendicitis and peritonitis, 
but in these conditions it is often associated with 
other germs. It may be found in inflammations 



SURGICAL CLEANLINESS 3 [ 

in any organ of the body. One of its pecularities 
is to invade tissue already occupied by other bac- 
teria or previously damaged. An idea recently 
advanced accounting for appendicitis in bicycle 
riders is that the appendix by the violent contrac- 
tion of the psoas muscle, causes a fertile soil for 
this germ to develop appendicitis. 

The gonococctlS, discovered by Neisser dur- 
ing 1879 in gonorrhoeal pus, has been proven to 
be the specific cause of gonorrhoea. But it was 
not until 1885 that it was made to grow outside of 
the human body. Bumm first cultivated it in 
human blood serum. The germ is found in pairs 
of biscuit-shaped bodies, with the flattened sides 
against each other. The peculiar feature of this 
germ is that it is often found included within the 
white blood corpuscle cell. It is strictly a human 
parasite. Pure cultures of it implanted in the 
healthy human urethra will invariably be followed 
by a genuine attack of gonorrhoea. 

This germ grows readily upon the conjunctiva, 
the mucous membrane lining the eye and covering 
the front of the eyeball. The inflammation caused 
by it in this situation is called gonorrhoeal oph- 
thalmia, and may be so severe as to cause destruc- 
tion of the eye. New-born infants sometimes 
have their eyes infected from their mother, the 
gonorrhoeal discharge from the mother coming in 
contact with the infant's eyes at birth. Again, 
nurses caring for infants with gonorrhoeal oph- 



32 SURGICAL CLEANLINESS 

thalmia have conveyed the germs to their own 
eyes through lack of disinfecting their hands after 
treating the child's eyes. Patients with gonor- 
rhoea have conveyed the disease to their own eyes 
With their infected hands. The germs live but a 
very short time outside of the human body, so 
that the disease is not often, if ever, conveyed 
through some inanimate object, such as the seat 
of a water closet. 

we recall two cases we have had under our care 
of little girls, not to exceed five years of age, who 
contracted the disease while sleeping with their 
infected mothers. 

This germ may cause salpingitis, pyosalpinx and 
ovarian abscess, also peritonitis. It may even 
cause inflammation of the joints, and of the cover- 
ing of the heart. The fact that this germ can 
cause gonorrhoeal rheumatism has been demon- 
strated as follows : The contents of the affected 
joint have been examined ; the gonococcus found 
to be the only germ present ; cultures from the 
contents of the joint have been made and the pro- 
duct injected into the healthy urethra, resulting 
in a genuine case of gonorrhoea. The so-called 
gonorrhoeal rheumatism is differentiated from the 
true by the simple fact that it affects but one joint 
while the latter affects several in succession. 

This germ imbeds itself in the epithelial cells so 
that it cannot always be reached by disinfectants. 
The germ may lie dormant a long time and lead 



SURGICAL CLEANLINESS. 33 

the individual to believe that he is cured. But 
any undue congestion to the sexual organs causes 
a reappearance of the disease. It is a common 
occurrence for a man who supposes himself cured 
of the disease to marry an innocent, healthy wo- 
man, who soon after marriage is attacked with 
gonorrhoea in the most violent form. The disease 
in her may end in an ovarian abscess, or an inflam- 
mation of the fallopian tubes causing sterility. 
Still graver trouble may occur. A peritonitis may 
be set up, causing her death, or a condition be 
brought about necessitating an operation for the 
removal of her ovaries, or womb, or all of her sex- 
ual organs. 

The bacillus of typhoid has been recently 
discovered to have some pyogenic properties. 
Suppuration of bone following an attack of typhoid 
fever is often caused by this germ alone. The 
usual habitat of the typhoid germ is in the intes- 
tines, or rather some of the mesenteric glands. It 
is worth while to incidentally note that there is a 
chemical difference between it and the bacillus 
coli communis, another inhabitant of the intestines 
already described. Cultures of the latter turn 
blue litmus paper red, showing acid reaction, 
while the typhoid germ does not. 

Speaking of typhoid germs reminds us of the 
discovery by which typhoid can be diagnosed from 
a drop of blood. 

From the patient a few drops of blood are se- 



34 SURGICAL CLEANLINESS. 

cured by pricking the finger with a needle and 
then smearing a drop or two upon a piece of clean 
glass — a bit of window glass will do — upon which 
it is allowed to dry. The piece of glass is then 
sent to a bacteriological laboratory, where they 
have pure cultures of typhoid germs. The live 
typhoid germs are in constant motion, which is 
very striking when seen under the microscope. 

Now, if the dried blood on the glass be moist- 
ened with a few drops of pure water, and the so- 
lution thus formed be poured into a live culture of 
typhoid germs the characteristic motion of the 
germs will stop almost instantly if the person from 
whom the blood was taken has typhoid. 

This recent discovery has been tested and found 
generally reliable. Thus, another triumph for 
bacteriology, the youngest of the medical sciences, 
is added. 

It will be of invaluable service in making an 
early diagnosis of typhoid and in differentiating 
typhoid from other diseases which in their earlier 
stages may be confounded with it. 

The typhoid germ reaches the intestines through 
the mouth, being usually taken into the stomach 
with the food or drink. Impure drinking water 
is the most common source of typhoid. When- 
ever an epidemic of typhoid occurs in any locality 
we may at once safely assume that the water or 
milk supply is contaminated. 

Boiling the water and the milk is the most ef- 



SURGICAL CLEANLINESS. 35 

fective means of preventing the disease. When a 
case of typhoid occurs in a family it is not unusual 
for the nurse and other members of the family to 
take the disease. From this fact it has been sup- 
posed that the germs of the disease might be car- 
ried in the atmosphere. This may be true, but 
we are inclined to attribute it to the use of the 
same infected drinking water, milk or food, possi- 
bly from eating from the same dishes or drinking 
from the same glass used by the patient. 

We have no doubt that a careless, ignorant dish- 
washer may wash the dishes so slovenly and in 
water insufficiently hot to destroy the germs, It 
requires water at a temperature of 133 degrees 
Fahrenheit for ten minutes to destroy or kill ty- 
phoid germs. 

The typhoid germ is one of the most difficult of 
disease germs to destroy. Some of the most 
powerful antiseptics will prove ineffective when 
added to the intestinal discharges from the typhoid 
fever patient. It is generally conceded that chlo- 
ride of lime is the most practical, and should be 
placed in the vessel before and after receiving the 
discharges. 

Too much care cannot be taken in thoroughly 
disinfecting all discharges from the typhoid fever 
patient at once. All soiled clothing and cloths 
should be burned or immersed in boiling water. 

The bacillus of tuberculosis, the germ of 
consumption, more often concerns the surgeon 



36 SURGICAL CLEANLINESS. 

than that of typhoid. It is estimated that one- 
fourth of all chronic surgical cases are tubercular. 
Of the seventy hospitals we visited during our re- 
cent trip abroad, we do not remember visiting a 
single general hospital in which we did not see 
several tubercular cases. 

As stated in the first chapter, the consumptive 
germ was discovered by Dr. Koch in 1882. Its 
length is about one-half the diameter of a red blood 
corpuscle. It requires boiling water to kill them, 
while the most resistant pyogenic germ, the staph- 
ylococcus, is destroyed at a temperature of 144 
degrees Fahrenheit. On the other hand, the for- 
mer is destroyed by a three per cent, solution of 
carbolic acid, while the latter requires five per 
cent. 

It may be said without a very great deviation 
from the truth that the consumptive germ is omni- 
present. This certainly is true in all our large 
cities and in certain districts, while in some of the 
higher regions of this and other countries it is ab- 
sent unless transported there by human beings. 

While the typhoid germ has never been known 
to affect animals, especially cattle, tuberculosis 
may be conveyed to human beings by using milk 
from a tuberculous cow. 

No doubt tuberculosis is most commonly dis- 
seminated by the expectorating of consump- 
tives upon floors and sidewalks, where the sputa 
dries and is ground up into dust and blown every- 



SURGICAL CLEANLINESS 37 

where to be breathed in by susceptible persons, 
who sooner or later develop consumption of the 
lungs or tuberculosis of some gland, joint or bone. 
A number of cities have already passed ordinances 
w r hich prohibit expectoration upon the sidewalks 
and in public buildings and conveyances. 

The question of quarantining consumptives is 
being agitated by the boards of health of some of 
the western states. In fact, California has al- 
ready taken steps to prevent consumptives enter- 
ing the state. 

It should be remembered that what was formerly 
called Scrofula, white swelling, hip joint disease 
and Potts disease of the spine, are only other 
names for that disease, which wdien it attacks 
the lungs we call consumption or pulmonary 
tuberculosis. The same germ causes all of these 
conditions to which in the past different names 
were given. Bone, joint and glandular tuber- 
culosis come within the domain of the surgeon. 
Under no other circumstances is surgical cleanli- 
ness more necessary than when operating upon 
any part affected with tuberculosis. If absolute 
surgical cleanliness is not secured during the ope- 
ration and maintained after it, the wound is not 
likely to heal. In no other place do pyogenic 
germs flourish so readily as in tissues affected 
with tuberculosis. Iodoform restrains the growth 
of tubercular germs as well, if not better, than 
any other agent. 



CHAPTER III. 

STERILISING. 

Thus far we have explained the importance of 
Surgical Cleanliness and showed the relation be- 
tween certain germs and certain diseases. We 
have also indicated what constitutes Surgical 
Cleanliness and made a few suggestions as to 
securing it. We shall now enter into the 
details. 

We have already stated that no germ of disease 
can survive contact with boiling water. This is 
absolutely true in case of all pus forming germs, 
but it is not quite true in the case of spore 
forming germs. Boiling water will destroy the 
adult germs, but the spores will sometimes survive 
even boiling water. This is true of the germs of 
tuberculosis. In order to kill the Spores and to 
render water absolutely sterile, it is necessary to 
boil the water three times on different days. On 
the first day the water is raised to the boiling 

38 



SURGICAL CLEANLINESS. 39 

point for half an hour and then allowed to stand 
in a warm room, which gives the spores an oppor- 
tunity to develop into adult germs. On the second 
day the water is boiled again and allowed to stand 
in a warm place. On the third day the process of 
boiling is repeated for the purpose of destroying 
any spores or germs that may have survived the 
second boiling. 

Water thus treated is spoken of as "thrice 
boiled" and may be considered absolutely Sterile. 
After water is rendered sterile by the three 
boilings great care must be taken to keep it 
sterile by putting it into closed vessels, which 
have been previously sterilized. Every operating 
room should have two or three large vessels full of 
sterilized water. A tin wash boiler with a tight 
fitting cover will answer for a vessel, although 
large glass jars with ground glass covers are now 
made for the purpose. 

After the hands have been thoroughly sterilized 
with chemicals, sterilized water may be used to 
cleanse them from the chemicals. Again, the 
sterilized water may be used to wash off the 
chemicals from the field of operation. The 
greatest use for sterilized water is in washing an 
aseptic wound. One in which there are no poison- 
ous element, but needs to be washed out for the 
purpose of clearing away the blood, so that the 
operator may inspect it thoroughly. However 
sponging the blood aw 7 ay with pieces of sterile 



40 SURGICAL CLEANLINESS 

gauze is more popular now than irrigating with 
sterile water. During the operation the surgeon 
has often occasion to wash off the blood from his 
hands. Here again the sterilized w 7 ater should 
be used, provided the hands have not become 
infected by touching something not surgically 
clean. In case they have become surgically 
unclean he must go through the usual process 
of sterilizing his hands, finally washing them 
in sterilized water. 

This naturally brings us to the question, how 
can the hands be Sterilised? If we could immerse 
them in boiling water and keep them there ten 
minutes, it would be a simple matter. This being 
physically impractical we must consider other 
means. Two or three different methods of ster- 
ilizing the hands are in vogue. The most com- 
mon one is as follows: 

Scrub the hands with soap and very warm water 
for five minutes. The scrubbing should be done 
thoroughly with a good brush, green soap or old- 
fashioned lye soap, such as our grandmothers used 
to make, is the best. Next, the hands should be 
washed with ether, for the purpose of dissolving any 
particles of fat or grease that may remain. The 
finger nails should be thoroughly cleansed while 
scrubbing with the soap and water. Next, the 
hand should be immersed for a minute or two in 
a solution of bi-cloride of mercury in the propor- 
tion of one to one- thousand, after which the hands 



SURGICAL CLEANLINESS. 4 1 

may be rinsed in sterilized water, for the purpose 
of washing off the extra amount of the chemicals. 
The laboratory tests show that bi-chloride of mer- 
cury is the most powerful antiseptic agent known; 
yet two facts regarding it should be kept in mind. 
It will not penetrate grease or fat; and that this 
chemical does not distribute equally over the sur- 
face. In some places there w T ill be a collection of 
the chemical, while in others there will be none. 
Ether must be used to remove the fat and grease 
before it is practical to use the bi-chloride. The 
second objection may be overcome by immersing 
the hand just before using the bi-chloride in a 
solution of ammonia and borax. This will cause 
the bi-chloride to be equally distributed over the 
surface of the skin. A common salt solution will 
do the same. 

Another method which is very common and 
much more practical, is to scrub the hands with 
soap and water thoroughly for five minutes and 
then immerse them in a five per cent solution of 
carbolic acid A solution of this strength of car- 
bolic acid gives an unpleasant biting sensation 
and may be followed by dizziness. While carbolic 
acid is far less powerful as an antiseptic than bi- 
chloride of mercury, it is far more practical, be- 
cause it readily penetrates fatty substances and 
uniformly distributes itself over the surface of the 
skin. Carbolic acid was the first surgical anti- 
septic employed by leister. The laboratory test 



42 SURGICAL CLEANLINESS 

by Koch showed bi-chloride of mercury so much 
more powerful than carbolic acid that surgeons 
for a w 7 hile showed a preference for the bi-chloride. 
Later the two objections to the bi-chloride which 
we have mentioned w r ere discovered; besides an- 
other, namely, its poisonous effect upon the 
wound. Cases of general poisoning have re- 
sulted from its use; besides death to some of the 
tissues of the wound. Recently carbolic acid has 
been more in favor; it is also open to the same 
objection of sometimes causing destruction of 
tissues and general poisoning. A New York 
surgeon states that he has been obliged to am- 
putate several fingers, which w 7 ere in the beginn- 
ing slightly injured but dressed w T ith too strong a 
solution of carbolic acid. The excessively strong 
solution of the carbolic acid caused gangrene of 
the fingers. 

The Weir method is highly recommended by 
some. We have found it hard on the hands. After 
the usual scrubbing w T ith hot w r ater and green soap 
place in the palm of the hand a scant tablespoon- 
ful of commercial cloride of lime, than nearly as 
much washing soda, add water and rub until the 
mixture resembles thick cream. Rub it into the 
palms, hands and arms until all particles of lime 
disappear or until a sense of coolness occurs, w r hich 
will be felt in usually four minutes. Rinse the 
hands in sterile water, when they are said to be 
surgically clean. 



SURGICAL CLEANLINESS. 43 

There is another method that we like best of all. 
It has stood the crucial bacteriological test. We 
mean by this that when this method has been em- 
ployed, scrapings from the hands placed in a cul- 
ture medium will not grow germs. The method 
is as follows: Scrub the hands for five minutes 
with very warm water and green soap, as in the 
other methods, then immerse the hands in a satu- 
rated solution of permanganate of potash, until 
they are colored to a mahogany brown. Next, 
immerse them in a saturated solution of oxalic 
acid until they are decolorized, and lastly in ster- 
ilized water, when they may be considered abso- 
lutely sterile. 

There is still another method of rendering the 
hands surgically clean. It consists simply in 
scrubbing the hands very thoroughly with, green 
soap and very warm water, and then bathing them 
with alcohol We know a surgeon who performs 
perhaps twenty operations a week and uses no 
other means for cleansing his hands. He tells us 
that he gets good results. This is certainly the 
simplest of all the methods we have enumerated. 
He objects to the frequent use of the bi-chloride 
of mercury, because it roughens the hands. This 
last method, however, will not stand the bacteri- 
logical test which should be our guide in choosing 
a method of sterilizing the hands. 

A young medical student, who knew but little 
about surgical cleanliness, was asked by his pro- 



44 SURGICAL CLEANLINESS. 

fessor to wash his hands until they appeared to 
be clean. The professor then scraped off a little 
of the epidermis from the student's hands and 
placed it in a culture medium. In about three 
days there was a luxuriant growth of germs. As 
already suggested, special care must be given to 
the finger nails. The nails should be evenly 
trimmed. The nail cleaner and nail brush should 
be conscientiously used. 

After the hands are once sterilized they will 
readily become surgically unclean, unless great 
precautions are taken. The tendency is great to 
touch something unclean. For instance, the 
scratching of the head, the smoothing back of 
the hair, taking hold of the table or chair, or 
the clothing of the patient, or the shaking of 
hands with a visitor, or rubbing against some one, 
or against one's own clothing, or wiping the nose 
with a pocket handkerchief. The latter is an ar- 
ticle that is especially filthy from a surgical stand- 
point. All of these things must be avoided. After 
the hands are once surgically clean, the motto 
should be, "Touch not!" A sterilized surgical 
gown entirely covering the clothing should be put 
on. This will protect the hands from one's own 
clothing. 

Next in order is the sterilizing of the instru- 
ments. So far as the metal instruments are con- 
cerned it is an easy matter for they can be boiled, 
and as already stated, boiling water destroys all 



SURGICAL CLEANLINESS. 45 

pus germs. If carbonate of soda be added to the 
boiling water in the proportion of 1 per cent, it 
will not only increase the disinfecting power of 
the boiling water, but it will prevent the instru- 
ments from rusting. This is a valuable point that 
should not be forgotten, for if instruments are put 
into cold water without the soda they will often 
rust within an hour. The common washing soda 
will answer the purpose. After the instruments 
have been in the soda solution they are easily pol- 
ished. Five minutes of boiling will thoroughly 
sterilize the instuments, provided the water con- 
tains soda. After instruments have been boiled 
some are in the habit of keeping them in a solu- 
tion of carbolic acid throughout the operation. 
Instruments should never be put into a solution 
of bi-chloride of mercury, because it will corrode 
them. 

The next link in the technique of performing an 
aseptic operation is the preparation of the field of 
operation. It is scarcely necessary to [state that 
the skin over the area to be operated on must be 
thoroughly scrubbed with soap and warm water, 
washed with ether and then with bi-chloride of 
mercury, in the proportion of one to one thousand 
and finally with alcohol. In case of an operation 
upon the abdomen, a poultice of soap is sometimes 
placed over the abdomen and allowed to remain 
for a number of hours. Sometimes a compress 
wrung out of a carbolized solution ranging from 2 



46 SURGICAL CLEANLINESS 

to 5 per cent is bound over the field of the opera- 
tion and allowed to remain until the surgeon is 
ready to use the knife. I have seen the skin 
blistered from using these drugs too strong or 
leaving compress on too long. The skin should 
be examined at the end of two hours. If there is 
any hair over the parts to be operated upon it 
should be shaved off before the compress is ap- 
plied. When time permits, it is customary to pre- 
pare the field of operation the day before, and 
then apply one of the compresses we have men- 
tioned and allow it to remain until the patient is 
upon the operating table. The part is then again 
thoroughly washed with soap and water, next 
with ether, then with bi-chloride and finally with 
alcohol. 

What w r e have said before in regard to unequal 
distribution of the bi-chloride should not be for- 
gotten. This may be prevented by washing the 
parts with a solution of ammonia and borax be- 
fore applying the bi-chloride. If the wound made 
by the surgeon is aseptic, that is, if it is free 
from germs or other infective substances, it should 
be irrigated w 7 ith nothing but sterilized w T ater pre- 
pared in the manner stated in the preceding chap- 
ter, or sponged with pieces of sterilized gauze. If 
the wound is septic, then it may be irrigated with 
a solution of bi-chloride of i to 4,000 parts, or a 2 
per cent solution of carbolic acid. In this con- 
nection we should state the fact that a solution of 



SURGICAL CLEANLINESS 47 

bi-chloride as weak as 1 to 10,000 will cause tissue 
necrosis in a fresh, aseptic wound, that is, it will 
cause some of the cells in the walls of the wound 
to die, a condition of things that is not desirable. 

A number of other chemicals may be used to 
irrigate a septic wound. Boric acid, acetate of 
aluminum and certain preparations of silver. The 
last are coming into favor and are likely to super- 
cede all others. The antiseptic power of certain 
products of silver is very great. It has the ad- 
vantage of being less harmful than the bi-chloride 
of mercury. It is a fact that certain bacteria will 
not grow in water contained in a silver cup. 
Formalin is increasing in popularity. The 
claim is made that it is the most powerful of all 
antiseptics and that it is not poisonous. In cases 
of aseptic wounds it is best not to irrigate at all. 
Instead of using a solution to wash away the 
blood, sponge the wound with dry sterilized 
gauze until all bleeding is stopped and the 
wound is free of blood. It seems to us that 
the washing of a clean wound even with ster- 
ilized water must have a deleterious effect upon 
the tissue cells most exposed. It surely washes 
away a part of their nutrition. 

It is a common poetical statement, "that life 
sometimes hangs by a single thread. ' ' In surgery 
it is often a reality. The thread or suture ma- 
terial may be the factor in determining the fate 
of a patient. It is scarcely necessary to say, that 



48 SURGICAL CLEANLINESS 

whatever substance is used for the stitches it must 
be surgically clean. If the suture material is sil- 
ver wire it can be readily sterilized by boiling it. 
If it is silk thread it may be treated in the same 
way, but if the suture is made from some animal 
substance, such as cat gut, silk worm gut or 
kangaroo tendon, it cannot be boiled without 
destroying its usefulness. Silver wire is but little 
used at the present time. The chief objection to 
it is the fact that it has to be removed. The 
same objection applies to silk thread, although it 
is possible for both of these to remain deeply im- 
bedded in the flesh without causing any dis- 
turbance. Silver, we have just noted, has great 
antiseptic power. Therefore, it is not likely to 
cause stitch abscesses. It is non irritating and 
has great strength. We saw exhibited in Uni- 
versity Hospital, Iyondon, an X-Ray picture of a 
silver wire suture w 7 hich had been in the knee five 
years and caused no annoyance. 

Cat gut is made from the intestines of sheep. 
The best cat gut is said to corne from Germany in 
the form of violin, guitar or banjo strings, Cat 
gut slips easier than silk and requires more care 
in tying. Cat gut is more irritable and less dur- 
able than silk. Chromicized cat gut however does 
not absorb under ten days. Cat gut prepared with 
formalin may be weeks in absorbing. Cat gut 
being an animal substance cannot be boiled in 
water without destroying its usefulness. It may 



SURGICAL CLEANLINESS. 49 

be boiled in ether or alcohol to remove the fat it 
normally contains. It has been stated that cat gut 
boiled one hour in alcohol is more servicable than 
when prepared with chemicals. In all methods of 
preparing it cat gut is usually treated first with 
ether to remove the fat. Then it is preserved in 
some germicidal substance or it is subjected to 
moist or dry heat to such a degree as will destroy 
all germs which are always found deep in its sub- 
stance when it comes from the manufacturers. 
Placing pieces of cat gut about twenty inches 
long in double envelops and then baking them in 
an oven heated to about 350 degrees F. is a 
method that is growing in popularity. The nurse 
or assistant removes the outer envelop without 
touching the inner one which is opened by the 
clean hands of the surgeon. Thus infection of the 
cat gut is avoided. 

Silkworm gut is sterilized by boiling. It is 
firm, smoothe, and not likely to become infected. 
It should always be used in closing wounds of skin 
where the least scar possible is desired, especially 
upon the face where regard is had for cosmetic 
results. Stitch abscesses are not likely to follow 
its use. It does not absorb. Horse hair stands 
next to silk worm in closing cutaneous wounds. 
It may be sterilized by boiling. 

Cat gut ordinarily absorbs within four or five 
days and for this reason does not have to be re- 
moved. This absorbable quality makes it 



50 SURGICAL CLEANLINESS. 

very desirable. The great disadvantage that it 
has is the difficulty of sterilizing it. Perhaps a 
hundred different methods have been suggested. 
Many of them will stand the bacteriological test 
in the laboratory, but after they have been buried 
in the living tissues a number of days, suppura- 
tion will take place around them and we have 
stitch abscesses. A single stitch abscess may 
cause entire failure of an operation. The most 
approved method at present is to keep the cat gut 
in a solution consisting of i part iodoform, 2 parts 
ether and 7 parts alcohol. The solution should 
be in a wide mouth bottle or glass jar with an 
air tight cover or stopper. The cat gut should be 
in the solution at least a week before it is used. 
It may, however, be kept in solution almost in- 
definitely. Cat gut kept in carbolized oil will not 
always stand the crucial test. 

If drainage tubes are used, they must, of course, 
be thoroughly sterilized, whether they be of rubber 
or of glass. This may be accomplished by boiling 
in a one per cent soda solution. If a gauze drain- 
age is used sterilized iodoform gauze is best and 
most commonly used. After the wound is sutured 
the line of incission should be dusted with iodo- 
form powder and over this should be laid iodoform 
gauze or plain aseptic gauze. Over this may be 
placed a layer of cotton and again other layers of 
plain gauze, and finally the roller bandage to re- 
tain the dressing in place. Iodoform, however, is 
being succeeded by less odoriferous agents. 



SURGICAL CLEANLINESS. 51 

It is essential that all dressings of a wound 
should be aseptic. Gatue and bandages are 
readily sterilized by boiling. But after the boil- 
ing it requires a great deal of care to dry them 
without their becoming re-infected by the germs 
transported by the dust of the atmosphere or by 
contact with unclean tables, vessels or hands. 

We recently saw on exhibition at the surgical 
instrument store of Truax & Co., Chicago, an 
apparatus costing about one hundred and seventy- 
five dollars which not only boils or steams the 
gauze but also dries it without removal from the 
cylinder in which it is placed. Only a few can 
afford the luxury of such an apparatus. There 
are however a number of sterilizers on the market 
costing less than twenty dollars which steam the 
gauze or linen until it is thoroughly sterile, and 
finally leaves it dry. New and improved steril- 
izers are being constantly placed upon the market. 
The general principle in all is the same. In cases 
of emergency at a farm house remote in the 
country we have used the teakettle and dish pan 
for sterilizers. We have had gauze, linen and 
towels satisfactorily sterilized many a time by 
boiling them in an ordinary tin wash boiler. 

After gauze is sterile and dry it should be placed 
in some absolutely clean vessel so that it w T ill not 
become re-infected. In most hospitals large glass 
jars having tightly fitting covers are commonly 
used. In taking the gauze from these it is more 



52 SURGICAL CLEANLINESS, 

convenient and more cleanly to use a long pair of 
sterilized forceps than the hands. The linen op- 
erating gowns worn by the surgeons and his 
assistants should be sterilized by boiling. After 
which they should be dried and kept wrapped up 
in sterilized linen until they are needed. 

To prepare iodoform gatue several methods 
are in use, but the simplest way known to us is 
to thoroughly saturate sterilized gauze with a mix- 
ture of ether and iodoform, in which the iodoform 
is present in the proportion of ten per cent. The 
gauze is then placed in an open shallow vessel or 
on a large clean plate and covered with a layer of 
sterilized gauze to protect it from the dust of the 
atmosphere. In a short time the ether will evap- 
orate and leave the iodoform evenly deposited upon 
the fibres of the gauze. When it has become dry 
it should be preserved in clean and tightly closed 
vessels. Before it is stored away it may be ren- 
dered still more antiseptic by immersing it in a 
solution of bichloride of mercury in the proportion 
of one to one thousand. It should never be for- 
gotten, however, that this last agent is a powerful 
poison. We have no doubt but that it will soon 
be supplanted in surgery by formalin or some of 
the other newly discovered ant iseptics which are 
equally or more effective as an antiseptic and less 
poisonous. 

To prepare a 10 per cent iodoform gauze, the 
following has come to our notice since writing the 



SURGICAL CLE INLTNESS. 53 

preceding: Take by weight 50 parts gauze, 40 
parts glycerine, and 10 parts iodoform, add 200 
parts of alcohol, and iod parts water, mix well. 
The alcohol and water will evaporate. The glyc- 
erine and iodoform will remain in the gauze. This 
method is accurate and the iodoform is not changed 
by the presence of ether as in the preceding method. 
The most suitable gauze weighs one ounce to the 
square yard. 

Boric acid, carbolic acid and other agents 
may be incorporated into gauze by saturating 
sterilized gauze with a solution of any one of 
them and then allowing the liquid portion to evap- 
orate. As already stated, iodoform gauze is more 
commonly used at present. Its germicidal power 
is small, its drying quality however is great. 
This accounts for the fact that while pus germs 
may continue to live in iodoform they do not 
thrive. The biniodide of mercury has several ad- 
vantages over the bi-chloride of mercury. It is 
said to be less poisonous, less likely to precipitate 
and more powerful as a germicide. 

If our surgical operations could always be abso- 
lutely free of all pus germs then there would be 
no occasion to use antiseptic gauze or any anti- 
septics. In fact many surgeons now use but little 
if any antiseptics, but they are scrupulously 
clean. Simple, plain aseptic gauze would answer 
all purposes and would be idealy consistent with 
our theory of perfect aseptic surgery. So long as 



54 SURGICAL CLEAXLIXESS 

it is practically impossible to do an absolutely 
aseptic operation, that is an operation in which 
not a single germ remains in the wound or in the 
dressings, it will be more satisfactory to use anti- 
septic gauze, that is gauze which has been im- 
pregnated with one or more of the various anti- 
septic agents. 



CHAPTER IV. 
REDRESSING. 

If a wound is aseptic, if the sutures are aseptic, 
if the dressings are aseptic, a redressing will 
not be necessary under ten days. The symptoms 
calling for a change of dressing is a rise of tem- 
perature, increase of pain, an increase of mois- 
ture and odor. So long as there are none of 
these no change of dressing is needed, and no 
change should be made at least within nine days, 
the time required for wounds to heal under the 
most favorable conditions. 

In case a wound is not clean as shown by the 
symptoms just mentioned, the sooner it is dressed 
the better. It must be redressed at least once a 
day thereafter. In some cases it is imperative to 
dress an infected wound two or three times a 
day. This is especially true where pus is burrow- 
ing into the neighboring parts and destroying 
tissue that should be saved. After the dressing 

55 



56 SURGICAL CLEANLINESS 

is removed and as much matter as possible is 
wiped away by means of dry sterilized gauze, the 
wound should be washed with a warm sterilized 
normal salt solution, that is, warm sterilized water 
with about one teaspoonf ul of salt in each pint of 
water. We have just read, that recent investi- 
gators find that the blood serum contains nearly 
one per cent salt instead of seven parts to the 
thousand, as we have been taught heretofore. If 
this be true, we should make a normal salt solu- 
tion nearly one per cent salt; that would require 
almost a teaspoonf ul and a quarter to the pint. 
The normal salt solution is rapidly superceding 
solutions of carbolic acid, bi-chloride of mercury 
and other chemicals for irrigating and douching 
purposes. Yet, there are cases where we may re- 
sort to these poisonous agents with satisfaction. 

While speaking of normal salt solution we must 
digress long enough to call attention to the great 
value of this agent in case of shock and excessive 
hemorrhage. Many a person well nigh pulseless 
from loss of blood and death seemingly inevitable, 
has been revived speedily by simply injecting un- 
der the skin from one to two quarts of normal 
saline solution. The method of introducing it is 
as follows. In the end of the tube of a fountain 
syringe tie a large hypodermic needle. Fill the 
syringe bag with normal salt solution at tempera- 
ture of ioo. Insert the needle in the loose folds 
of skin, particularly under the breast. Avoid in- 



SURGICAL CLEANLINESS. 57 

jectiug air. Unless surgical cleanliness is observed 
troublesome abscess may follow where the needle 
entered. 

We can recall a number of cases of surgical 
shock, hemorrhage, congestive chill, blood poi- 
soning, revived and in all probability saved by in- 
jecting normal salt solution. This agent is used 
by many surgeons in washing out the abdominal 
cavity after it has become infected by the rupture 
of an internal abscess, or in case of purulent peri- 
tonitis. A distinguished surgeon has j ust reported 
the recovery of an apparently hopeless case of 
purulent peritonitis. He attributes her recovery 
to the fact that during the first seventy-two hours 
after the operation in which he opened the ab- 
domen, he caused three hundred gallons of warm 
normal salt solution to run into and out of the ab- 
dominal cavity, thus keeping its contents bathed 
continually with it. 

One of the most useful agents in cleaning a 
wound of pus is peroxide of hydrogen. It is 
not poisonous. As soon as it comes in contact 
with pus it sets up an efferversence resembling 
the foam on soda water. The pus corpuscles are 
actually consumed by the peroxide of hydrogen. 
A chemical union occurs which disintegrates the 
pus. If there is any objection to the use of per- 
oxide of hydrogen it is the quality of being 
slightly irritating. We can remember when this 
agent was introduced into surgery about fifteen 



58 SURGICAL CLEANLINESS. 

years ago. Before that its only commercial use 
was to bleach the hair of actresses. 

While speaking of the abdominal cavity and its 
contents we will here digress again a little to state 
a most important caution. The medical journals 
are just now discussing the case of a distinguished 
surgeon who has been sued for $10,000 damages, 
because a sponge was overlooked and sewed up in 
the abdomen, causing the death of the patient. 
It may be surprising to our readers, but neverthe- 
less this is a very common mistake. Not only 
sponges, but scissors, forceps and other instru- 
ments have been employed during an abdominal 
operation and left inside by mistake. We attended 
a convention of gynecological surgeons once during 
which this oversight was discussed. More than 
twenty-five of such mistakes were confessed then 
and there. The unfortunate surgeon who has re- 
cently been sued defends himself by stating, that 
it was the duty of the surgical nurse to count the 
sponges, and that when he was ready to close up 
the abdomen he asked the nurse the usual quest- 
ions. Have you counted the sponges? Are they 
all out? She answered in the affirmative and he 
closed the wound. The trial of this case will 
probably determine to what extent the nurse is 
responsible. Must she bear a part of it or must 
the surgeon bear all the blame? 

There are several places upon the body where 
special attention to surgical cleanliness is of very 



SURGICAL CLEANLINESS. 59 

great importance. For instance, an infection of 
the eye requires prompt and constant attention to 
make it surgically clean. The eyes of a large per 
centage of new born infants become infected 
during the first or second week after birth. If 
they are not treated promptly with a view to se- 
cure surgical cleanliness the sight of one or both 
eyes are often lost. A thorough knowledge of 
this subject would have made blind asylums hardly 
necessary. In some countries stringent laws have 
been passed in regard to the care of the eyes of 
the new born. One advanced practitioner tells us 
that he washes out the eyes of every infant soon 
after birth with a two per cent solution of nitrate 
of silver. It is a safe practice for the nurse or 
mother to wash out the infants eyes with a two or 
three per cent solution of boric acid. Especially 
should this be done upon the slightest appearance 
of a discharge from the eye. 

A discharge from the ear is often followed by 
serious concequences if surgical cleanliness is not 
observed. The cleaning of the ear is not an easy 
matter. Some are opposed to throwing any kind 
of a solution forcibly into the ear. If the head be 
placed on the side with the affected ear upward 
there cannot be any very great risk in pouring 
into the ear a warm medicated solution of glycer- 
ine. Pure or medicated glycerine being heavy will 
cause the pus to rise to the surface and float out. 
Incidentally we would say that one of the most 



60 SURGICAL CLEANLINESS. 

effective applications for relief of acute earache is 
to pour into the ear a solution consisting of one 
part carbolic acid and nine parts glycerine. Boric 
acid powder is often blown into the ear to dry up 
a discharge. This is open to the serious objection 
that the powder sometimes forms a crust and 
blocks the escape of the pus. Instead of aiding 
the egress of the matter the result is the opposite. 
The pus is forced to burrow in some direction that 
may cause serious complications, for instance into 
the brain. 

It is a frequent occurrence for an abscessjto 
form at the root of a tooth and spread into the 
neighboring tissue, causing much damage. It is 
safe to say that if the mouth could be kept always 
surgically clean we w r ould have no such abscesses 
which often follow 7 dow r n the lymphatic channels 
into some gland of the neck, causing it to swell up 
and break down from suppuration. 

The tonsil is often the seat of an abscess which 
is called suppurating tonsillitis or "quinsy." Pus 
germs lodge in the crypts of the tonsils. A chill- 
ing of the neck or w r hole body is followed by a 
congestion, which puts the tonsils in a favorable 
condition for the development of abscess and other 
troubles far more serious. Suppurative endocar- 
ditis and death have followed abscess of tonsil. 
Many troubles called rheumatism have started 
with suppurative tonsilitis. It is now believed, 
that the pus from the tonsil gets into the lym- 



SURGICAL CLEANLINESS. 6 1 

phatic channels and is carried into the blood ves- 
sels and heart. Sudden death during diphtheria 
is a common occurrence. It is credited to heart 
failure. The cause no doubt is the absorption of 
the germs or their toxins into the circulation. 

A disinfecting of the throat becomes an important 
matter. Many agents have been used. Alcohol 
and water in equal parts is a simple and convenient 
gargle. It is believed to possess great merit. 
Seilers tablets make a good, mild gargle. A 
grain of permanganate of potash in a glass of 
water is a very excellent disinfecting gargle. It 
possesses much merit and has stood the test of 
long usage. A combination of salt, water and 
vinegar is a domestic gargle which stands well the 
light of modern science. We have already dis- 
cussed the value of salt water in surgery. 

As for vinegar it has been shown to possess con- 
siderable antiseptic power. One eminent anthority 
has gone so far as to say that it is as powerful as 
bi-chloride of mercury. It is related that once 
upon a time during a cholora epidemic two men 
robbed the clothing of the dead with impunity, so 
far as taking the disease. The secret of their im- 
munity was said to have been due to the fact that 
each morning before going out upon their ghonlish 
expedition they bathed their entire bodies with 
vinegar. 

A one per cent solution of carbolic acid makes a 
useful gargle. One of the most effective and at 



62 SURGICAL CLEANLINESS. 

the same time one of the most dangerous to use 
as a gargle, is a solution of bi-chloride of mercury. 
It should not be used in the throat stronger than 
one part in ten thousand. We have known 
nurses to use it successfully to gargle their own 
throats, while nursing cases of diphtheria. 

The disinfecting of the stomach does not con- 
form to the usual rules of disinfection. A normal 
stomach disinfects itself. The free hydrochloric 
acid which is normally present in the gastric juice 
is a natural antiseptic, and when the stomach is 
in a healthy condition it keeps the stomach in pure 
condition. When the stomach becomes over loaded 
or when by disease the gastric j uice becomes ab- 
normal, disease germs may exist in the stomach. 
It is at once apparent that poisonous chemicals 
cannot be used to cleanse the stomach. Much can 
be done towards cleaning the stomach by washing 
it out with plain water, or water containing a 
small quantity of boric acid or bicarbonate of soda. 
The stomach tube consists of a rubber tube, about 
three eight of an inch in diameter and about two 
feet long. The upper end of the tube is expanded 
into a funnel so that water can be readily poured 
into the tube. The tube is lubricated; the best 
substance for this purpose being the white of an 
egg. The small end of tube is placed far back 
into the patients mouth and told to swallow it 
rapidly. This is usually accomplished after a little 
urging on the part of the physician or nurse. As 



SURGICAL CLEANLINESS. 63 

soon as it is inserted, the fluid is poured into the 
funnel end of the tube. When ii is desired to 
evacuate the stomach after it is filled with the 
washing fluid, the funnel end of the stomach 
tube is lowered beneath the level of the stomach. 
Thereupon the contents of the stomach is at once 
siphoned out. 

Strong antiseptics should not be used in the 
rectum, because they are likely to be absorbed 
and cause general poisoning. We saw- one case 
and have read of others, where a strong carbolized 
solution injected into the rectum was followed by 
a sort of a convulsion and unconsciousness. 

Stronger antiseptics may be used in the vagina. 
Yet some persons are very sensitive to chemical 
poisons used in a vaginal douche. We recall a 
case where a solution of bi-chloride in the propor- 
tion of 1 to 4000 w r as followed by salivation , or at 
least marked ptyalism. A solution of 1 to 8000 of 
bi-chloride of mercury is sufficiently strong to use 
in a vaginal douche. Boric acid, carbolic acid, 
permanganate of potash as well as many other an- 
tiseptics may be used in the vaginal douche. In 
case of genorrhseal infection the permanganate of 
potash solution in the proportion of one grain to 
the pint, or a little stronger, gives good satis- 
faction. 

There is one antiseptic which we have neglected 
to emphasize and that is mustard flour. It has 
the advantage of being a vegetable instead of a 



64 SURGICAL CLEAXLIXESS. 

mineral, as nearly all other antiseptics are. It is 
not poisonous. It is said to be nearly as powerful 
as bi-chloride of mercury. It can be mixed in 
water and used to wash the hands, or it can be 
used as a douche. It could be used in the stomach. 
In fact, it is the only powerful antiseptic that we 
could safely use in the stomach. A number of 
successful surgeons use nothing else but mustard 
flour water in which to sterilize their hands. 

Speaking of vegetable antiseptics reminds us 
of another one, and that is turpentine. It has 
really great antiseptic power. The late Mr. Tait, 
the world's most famous gynecological surgeon, 
condemned antiseptics but we recall the fact, that 
he used turpentine quite freely in washing his 
hands and for other purposes. 

The disinfection of the bladder is often neces- 
sary. It can be disinfected by giving the patient 
four times a day a cup of warm water to drink in 
which is dissolved from five to ten grains of boric 
acid. This way is very easy and generally satis- 
factory. It is surprising how quickly the foul am- 
moniacal odor of the urine disappears after this 
treatment is begun. The boric acid escapes through 
the kidneys. 

There are cases in which it is necessary to wash 
out the bladder. Here again, a solution of boric 
acid is about the only antiseptic we can safely em- 
ploy in washing out the bladder. Three teaspoons 
f ul of boric acid may be dissolved in a quart of 



SURGICAL CLEANLINESS. 65 

water. This will make approximately a one per 
cent solution. A weak solution of iodine may be 
used in some conditions of the bladder, especially 
tuberculosis. 

There remains still another place upon the body 
where surgical cleanliness will save a vast amount 
of suffering. We refer to the nipples of nursing 
women. Abscess of the breast is always caused 
by an infection. The pus germs find entrance 
through some abrasion or irritation about the 
nipple. If the breast is left surgically clean it 
will be impossible for a woman to have a "broken 
breast,' ' one of the most painful affections known 
to women. Before and after the child nurses the 
nipples should be cleansed. Before the child is 
ever put to the breast, the nipples should be 
cleansed with soap and water. Then washed with 
a boric acid solution and finally washed with 
alcohol. 

The wearing of thin rubber gloves while op- 
erating is gaining favor with surgeons. If the 
gloves are thoroughly sterilized, which can be 
readily done by boiling, no infection can possibly 
occur to the wound from the operators hands. 
We know of one very successful surgeon, who 
will not operate without gloves and will not per- 
mit any one to assist him who does not wear them. 
Knowing how difficult it is to sterilize the hands 
and how much labor it takes to teach assistants 
how to sterilize their hands, we must endorse the 



66 SURGICAL CLEANLINESS. 

position this surgeon has taken, but gloves are 
not always at hand and they are expensive. Be- 
sides they are likely to be ruptured in the midst 
of an operation. The finger nails should re- 
ceive great attention as to cleanliness. They 
should be manicured often. In the debris un- 
der the finger nails is a favorable place for pus 
germs. It is scarcely necessary to say, that the 
Operating room should be clean and free from 
dust. It is a fact that pus germs are not very 
abundant in the dust of the atmosphere. If the 
floor is washed with an antiseptic solution a half 
hour before the operation there cannot be much 
dust stirred up, and the dust previously in the 
atmosphere will be largely precipitated to the floor 
and held there by the moisture. 

I/aughing, coughing, sneezing and unneces- 
sary talking should be avoided in the operating 
room. There are very few persons whose mouths 
are so clean as not to have some decayed teeth 
with ulcerating roots and abscesses of the gums. 
Unless care is taken a small particle of saliva laden 
with pus germs might easily be thrown from the 
mouth into the wound. The operator and his as- 
sistants should avoid breathing into the wound. 
Few surgeons can perform a major operation 
without perspiring freely. Care should be 
taken that the perspiration does not drop from 
the surgeons face into the wound. A watchful 
nurse will see that the perspiration is wiped away 



SURGICAL CLEANLINESS. 67 

as often as necessary. It is well to cover the hair 
and beard with gauze to guard against infected 
particles falling from thern into the wound. 

It seems almost unnecessary to state that spec- 
tators with unsterilized hands and unclean cloth- 
ing should keep away from the operator and his 
assistants. Yet this caution is necessary. We have 
seen intelligent persons who would be supposed to 
know better rub up against the surgeon or his as- 
sistants wholly unmindful that they were risking 
the success of the operation. 

The Sterilisation of Catheters and 
Bougies. 

Nicoll gives the following directions for the 
sterilization of catheters and bougies: 

Bougies.— Gum-elastic bougies will not bear 
heating to a temperature sufficient for steriliza- 
tion. Soaking for fifteen minutes in carbolic acid 
solution 1 in 20, for half an hour in 1 in 40, or 
for an hour in perchloride of mercury 1 in 1000, 
renders the surface so sticky that the towel ad- 
heres in the process of drying, and the bougie be- 
comes covered with fluff. After several soakings 
the surface becomes permanently dull and sticky 
and unfit for use. Dr. Schimmelbusch says that 
"a smooth bougie or catheter can mechanically be 
made externally free from germs by rubbing it 
with a piece of sterilized gauze and warm water. ' ' 



68 SURGICAL CLEANLINESS. 

To test this, series of six gum-elastic bougies in 
use from six to eighteen months, after being em- 
ployed in cases of stricture, were washed with 
tepid water and soap, rinsed in cold running 
water, and dried by thorough light friction 
with sterilized gauze. They were then rubbed 
on the surface of acid and alkaline agar tubes. 
In one case colonies of an unidentified coccus ap- 
peared, in another a patch of penicillium. The 
other ten tubes remained sterile. Six bougies 
soiled with pus were similarly treated; all the 
tubes remained sterile. In other experiments in- 
stead of the gauze an ordinary towel fresh from 
the laundry was used, and similar results were ob- 
tained. It appears, therefore, that antiseptic solu- 
tions which rapidly destroy instruments are un- 
necessary for sterilization. 

Catheters — Red rubber catheters (Jacques) may 
be sterilized by boiling or steaming, or may be 
soaked for months in carbolic solution, i in 20, 
or perchloride of mercury, 1 in 1000, without 
damage. A rubber catheter may be used daily 
for six months without becoming unfit for use, if 
washed every day with hot water and soap and 
put to soak in carbolic lotion for the remainder of 
the twenty- four hours. But there are certain red 
rubber catheters which rapidly deteriorate under 
repeated boiling, and all rubber catheters ulti- 
mately do so. Prolonged and repeated soaking 
in antiseptics has little effect. By experiments the 



SURGICAL CLEANLINESS. 69 

writer has proved that rubber catheters, boiled, 
steamed or soaked for four hours in the lotions 
mentioned, are rendered sterile internally and ex- 
ternally. But gum-elastic catheters, like bougies, 
will not stand the lengthened and repeated soaking 
necessary for sterilization. There is no entirely 
reliable method. For practice the writer has form- 
ulated the following rules: 

1. Avoid as far as possible the employment of 
catheters. In cases of stricture it can only be very 
exceptionally that a catheter is called for. Bou- 
gies, which are readily sterilized, will do all that 
is necessary. 2. Where a catheter must be em- 
ployed, use where possible a red rubber Jacques 
catheter in preference to a gum-elastic. In reten- 
tion from atony, spinal paralysis, reflex nervous 
effects and other causes, and in many cases of 
prostatic retention, the former answers as well, 
and is as readily sterilized by boiling or immersion 
in an antiseptic solution as is a metal catheter. 
3. Where the red rubber fails to pass, the use of 
metal catheters, especially by the patient, does not 
commend itself as free from risk of injury. 

Gum- elastic catheters must therefore be used. 
If the urine is very septic the writer destroys the 
catheters used. If the urine is not very purulent 
or offensive, he washes the catheters externally 
with soap and water, and then with antiseptic so- 
lutions, which is followed by internal steaming. 
Those that survive he retains. When the regular 



70 SURGICAL CLEANLINESS. 

use of a gum-elastic catheter is necessary, the 
patient is supplied with a catheter with a well-fin- 
ished interior. After use he thoroughly washes it, 
holds it under the tap for a few minutes and lays 
it aside in boric acid, weak perchloride, or other 
weak antiseptic. This only offers a reasonable 
chance of asepsis, but it is useless to expect an 
average patient to carry out more elaborate plans. 
The writer has had glass tubes constructed, which 
are filled with the antiseptic solution, in which 
the catheter is placed after use. The solution 
varies in strength according to the kind of cathe- 
ter; for gum-elastic catheters it must be weak, 
red rubber catheters will stand anything. 

Preparation of the Abdomen for 
Operation. 

The following procedures are carried out in the 
John Hopkins Hospital in the preparation of the 
abdomen for operation: 

On the day before the operation the ward nurse, 
using a gauze mop, washes the skin with green 
soap and water. With disinfected hands she then 
washes the area with alcohol, ether and mercuric 
bichloride solution ( i : i ooo) . A large sterile gauze 
shield is then laid over the cleansed part, this being 
held on with tapes. In the operating-room, after 
the patient is anesthetized and on the table, the 
preparation is continued in two stages. The first 



SURGICAL CLEANLINESS. 71 

stage is done by an assistant whose hands are not 
necessarily completely sterile. The second stage 
is done by the assistant with clean hands. The 
first stage consists in removing the ward dressing, 
lathering with green soap and water, shaving and 
flushing; washing wdth green soap and water, em- 
ploying a gauze wash-ball; flushing with ether, 
washing off with sterilized water. The second 
stage consists in washing thoroughly with green 
soap and water, using a wash-ball; flushing with 
ether, flushing with alcohol, and flushing with 
mercuric bicloride (1: 1000). In those cases with 
old scarred skins or slight dermatitis, potassium 
permanganate and oxalic acid are also used. 
There is then a final flushing with sterile water. 
This whole process is done in from ten to twelve 
minutes. 



CHAPTER V. 
Current Opinions on Disinfection. 

At a meeting of the Chicago Medical Society, 
Jan. 17, 1900, the subject of disinfection was dis- 
cussed. The following is the essence of the con- 
clusions and present opinions of several eminent 
surgeons who took part in the discussion: 

For mental, physical and antiseptic reasons the 
patient should enter the hospital 24 to 48 hours 
before the operation. The preliminary steps in dis- 
infection is mechanical, consisting largely of rub- 
bing away masses of loose epidermal scales to 
which germs are attached. This is best accom- 
plished by soap and warm water applied with a 
stiff nail brush. All agreed that too much confi- 
dence is placed in so called antiseptics. All of 
which are more or less poisonous, and if used in 
sufficient strength to kill germs, will injure the 
tissues. A general bath should be the first step in 
preparing a patient for the operation. Schleich's 

72 



SURGICAL CLEANLINESS. 73 

marble dust soap was recommended as better 
than green soap. It should be used with a piece 
of sterilized gauze and not with a brush. 

Rubber gloves were recommended. They 
should be prepared as follows: Wash in- and out- 
side with a 10 per cent solution of sodium carbo- 
nate. Rinse in sterilized water, dry for one 
minute over a gas flame, reversing. Dust inside 
liberally with sterilized soap, shoe powder. 
Wrapp in double layer of sterilized gauze and 
put in a formaldehyde sterilizer for two hours. 
Then lay away wrapped in sterilized towels labeled 
with size and date of sterilization. This method of 
sterilizing gloves has been found to be superior to 
all others. Repeated and numerous tests for germs 
even two weeks after this method has been em- 
ployed has revealed no germs in the gloves. 

In dry operations woven gloves have a place. 
Cotton is safer than silk, but neither compares 
with rubber. Cotton gloves are cheaper than rub- 
ber. Cotton gloves may be used in both aseptic 
and septic operations. In the former to protect 
the patient from being infected by unclean hands, 
and in the latter condition to protect the operators 
from being inocculated with septic matter. Nu- 
merous bacteriological tests of the inside and of 
the outside of cotton gloves, after operations, 
showed that the operator's gloves were infected on 
the inside in two thirds of the cases, while the in- 
side of the gloves worn by the nurse, who handed 



74 SURGICAL CLEANLINESS. 

instruments, ligatures, sponges and dressings to 
the operator, were not infected at all. Illustrat- 
ing the fact that the exertions and perspiring of 
the operator brought the germs to the surface 
through the sweat glands, which was not the case 
with the hands of the nurse who was compara- 
tively inactive. 

Theoretically it is well nigh impossible to thor- 
oughly and absolutely sterilize the skin of the 
patient or that of the operator. Practically it is 
an easy matter to secure a degree of surgical 
cleanliness that will insure healing by first inten- 
tion. Theoretically strong chemical disinfectants 
are required for the purpose of sterilizing the 
hands, but practically careful washing with the 
mildest soap and water, following with a rinsing 
with alcohol is absolutely sufficient and very much 
safer for the patient, because hands roughened by 
the use of strong antiseptics are much more likely 
to become hopelessly septic, than those that are 
covered with smoother, healthy skin. It is easy 
to keep the hands sterile, after they have once 
been rendered aseptic. And yet, no task is more 
difficult in a surgical clinic than to keep all hands 
interested clean. 

Deep stitches through the skin make a direct 
communication for the germs in the skin to pass 
into the deeper aseptic tissues. But such stitches 
never cause infection, so long as they are not 
drawn too tight. Tension causes pressure necrosis, 



SURGICAL CLEANLINESS. 75 

that is, the nutrition is cut off by pressure, and 
death of the part follows, making a fertile soil 
for the development of the germs, to result in 
stitch abscesses or something more serious. Cat 
gut stitches are safe if not drawn too tightly. 
Theoretically a surgeon may sterilize his hands 
after dressing pus cases and operate immediately 
upon clean cases, but practically such a custom is 
followed by bad results through accidental infec- 
tion. In spite of the greatest care, something that 
was used in connection with the unclean cases will 
accidentally come in contact w 7 ith the skin. It is 
better therefore to operate upon clean cases first, 
and dress or operate upon the unclean ones last. 
The surgeon and his assistant should be careful 
not to breathe or speak into the wounds. 

Whenever drainage is used in clean wounds it 
should be removed within twenty-four hours. If 
it is done this early, infection is not likely to oc- 
cur from drainage. The peritoneum is rarely if 
ever infected from the air. In some cases of peri- 
toneal infection the abdomen may be filled with 
normal salt solution, and so dilute the poisons as 
to tide the patient over the danger point. The 
peritoneum is more likely to be infected from the 
surgeon's hands or the patient's skin. Blood clots 
can be removed from the peritoneum better by a 
dry aseptic sponge than by an irrigating fluid. 
Intra-venous injection of normal salt solution is 
the best method of treating shock. 



76 SURGICAL CLEANLINESS. 

Puerperal Sepsis. 

We can think of no more fitting way to close 
this volume on Surgical Cleanliness than by a 
brief survey of the steps that have led up to the 
discovery of the fact that puerperal sepsis and 
surgical fever or blood poisoning are one and the 
same. More than fifty years ago, a few medical 
writers intimated this truth, but they were sever- 
ely ridiculed and abused by the authorities and 
leading men of their time. What was hinted at 
forty years ago has become universally recognized 
as truth during the last five or ten years. 

Dr. Oliver Wendell Holmes's article on "The 
Contagiousness of Puerperal Fever,' ' in 1843 must 
ever remain a Classic. The closing paragraph of 
Holmes's paper was as follows: 

"I have no wish to express any harsh feeling 
with regard to the painful subject which has come 
before us. If there are any so far excited by the 
story of these dreadful events that they ask for 
some word of indignant remonstrance to show 
that science does not turn the hearts of its follow- 
ers into ice or stone, let me remind them that 
such words have been uttered by those who speak 
with an authority I could not claim. It is as a 
lesson rather than a reproach that I call up the 
memory of these irreparable errors and wrongs. 
No tongue can tell the heart-breaking calamity 
they have caused; they haye closed the eyes just 



SURGICAL CLEANLINESS. 77 

opened upon a new world of love and happiness; 
they have bowed the strength of manhood into 
the dust; they have cast the helplessness of in- 
fancy into the strangers arms, or bequeathed it, 
with less cruelty, the death of its dying parents. 
There is no tone deep enough for regret, and no 
voice loud enough for warning. 

"The woman about to become a mother, or with 
her new-born infant on her bosom, should be the 
object of trembling care and sympathy wherever 
she bears her tender burden or stretches her aching 
period. The very outcast of the street has pity 
upon her sister in degradation, when the seal of 
promised maternity is placed upon her. The re- 
morseless vengeance of the law brought down 
upon its victim by a machinery as sure as des- 
tiny, is arrested in its fall at a w r ord which re- 
veals her transient claim for mercy. The solemn 
prayer of the liturgy singles out her sorrows from 
the multiplied trials of life, to plead for her in the 
hour of peril. God forbid that an}' member of the 
profession to which she trusts her life, doubly 
precious at that eventful period, should hazard it 
negligently, unadvisedly, or selfishly." 

Holmes's theory that child-bed fever was con- 
tagious, and his appeal for surgical cleanliness 
brought down upon him the severest ridicule of 
the most brilliant minds of his age. Notwith- 
standing this abuse, the doctrine of "The Con- 
tagiousness of Puerperal Fever" grew. To Hirst 



78 SURGICAL CLEANLINESS. 

in his excellent work upon Obstetrics we are in- 
debted for the following remarkable narrative: 

"In 1846 a young assistant in the Maternity- 
Department of the General Hospital of Vienna, 
named Semmelweiss, was struck with the fright- 
ful mortality in one of the Maternity Wards of 
the General Hospital, while in a neighboring 
ward the death-rate was scarecely one- tenth as 
great. He discovered that in the first ward the 
women were attended by students who were in 
the habit of coming fresh from post-mortem ex- 
aminations in the Pathological Department to the 
bed-sides of the parturient patients. In the sec- 
ond ward the women were attended solely by mid- 
wives. 

"Semmelweiss conceived the idea that the 
students carried on their hands putrid products 
from the post-mortem table to the lying-in women 
whom they examined. And that these products 
were responsible for the large number of fatal in- 
flammations and fevers that followed the student's 
work. He consequently ordered that no student 
should examine a woman until he had washed his 
hands in chlorin-water. The results of his regu- 
lation were fairly startling, as is shown in the ac- 
companying table: 

Confinements. Deaths. Per Cent. 

1846 4010 459 n*4 

1847 3490 176 5 

1848 3556 45 1*27 



SURGICAL CLEANLINESS. 79 

"It should be stated that the rule compelling the 
students to wash their hands in an antiseptic so- 
lution was put into effect in the middle of the 
year 1847. 

"Semmelweiss recognized the transcendent im- 
portance of his discovery. He foresaw something of 
the lives preserved, the homes kept from bereave- 
ment, the mothers saved to their children, the 
wives to their husbands, in millions of families; 
the incalculable diminution of human suffering 
which his discovery promised to the world; but 
his was not the calm and confident soul of a Har- 
vey, wise enough to know that the truth is mighty 
and shall prevail: sure that mankind must accept 
it some day, and content to bide his time. Sem- 
melweiss' nature was not great enough for such 
patience. He fumed and fretted his life away in 
vain efforts to obtain recognition for his great 
principle of chemical disinfection. He preached 
his new doctrine in season and out of season, en- 
deavoring to impress it upon his immediate col- 
leagues, and upon the medical societies and peri- 
odical medical literature of the time in Europe. 
During the latter days of his professorship in 
Buda-Pesth he would even stop aquaintances 
upon the street to importune them with his 
views. But he got for his pains nothing but 
ridicule, contumely, opposition, or indifference. 
He finally lost his mind entirely, from chagrin 
and disappointment, ending his life in a lunatic 



8o 



SURGICAL CLEANLINESS. 



asylum in Vienna, where he died, strangely e- 
nough, from a septic wound on his finger re- 
ceived during an operation performed just before 
his commitment to the asylum. 

"More than twenty years after Semmelweiss' 
discovery, the mortality of many lying-in hospitals 
in Europe remained as high as ten percent. Then 
came the brilliant work of Pasteur in the field of 
bacteriology, the acceptance of the germ theory in 
disease, the application of antisepsis to surgery by 
Lister, and the adoption of the system almost im- 
mediately by obstetricans. From that day to this 
there has been a steady and increasingly rapid ac- 
quisition of knowledge of the etiology of septic in- 
fection, and of its most successful preventive and 
eurative treatment. 

"It is to be hoped that the medical world of to- 
day and of the future can never again be deaf and 
blind to such an appeal as that of Holmes, or to 
such a demonstration as that of Semmelweiss " 



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